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Solve the Medical Riddle: The Patient Is No Longer “Regular”, Fourth Week

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By Marie Savard MD

Editor’s note: Welcome to our ThirdAge feature that gives you a chance to play medical sleuth as we share the details of what happened when a patient presented with a problem that stumped the physician at first.

The first week of this riddle, the patient reported her symptoms and the doctor proceeded with the examination. This was step #1, S, of the classic the classic S-O-A-P notes as follows:S=Symptoms or Chief ComplaintO=Objective FindingsA=Assessment or AnalysisP=Treatment Plan or Recommendations

The second week, the doctor moved on to O and A=Assessment or Analysis to continue to look for clues to the medical riddle. Last week, we let you know what some people had suggested as possible diagnoses. This week, the doctor will move on to P to reveal the actual diagnosis as well as outline treatment options and lifestyle recommendations. Then we’ll begin a new riddle for the following month!

The Doctor Reveals the Diagnosis

Congratulations to Mary S. who came the closest to the actual diagnosis for Sally’s chronic constipation when she said she thinks Sally just “holds it too long”! Thumbs up also to Carol M. who questioned whether Sally is drinking enough water. In view of Sally’s history of reduced physical activity/exercise, reluctance to use the toilet near the teachers’ room at the school, and her habit of postponing bowel movements, I diagnosed Sally with a problem that is popularly called “safe toilet syndrome”. This is a surprisingly common issue, especially, for women. The diagnosis does not have an ICD 9-CM code (soon to be ICD-10)
, by which I mean the International Classification of Diseases, Ninth Revision, Clinical Modification. That is the official system used in the United States to classify and assign codes to health conditions.
Even so, the actual label or precise diagnostic name is less important than the cause. Sally was quit literally afraid to use a toilet away from the safety of her own bathroom, especially if she felt others could hear her efforts to have a bowel movement.

Beyond that, she had experienced multiple lifestyle and functional changes that led to unhealthy modifications in her daily routine. Fortunately, though, she was not taking any offending over-the-counter supplements such as calcium carbonate, which is the form of calcium most likely to cause constipation, or multivitamins with iron, which is another cause of constipation. She was also not on any prescription medications that might cause constipation, such as calcium channel blockers to treat high blood pressure.

One of the main contributing factors to Sally’s constipation was her lack of exercise since she used to walk to and from school and now she drives, and she doesn’t play tennis or chase after her grandchild any longer.